Cherie P. Brunker

The Effect of Technology-Supported, Multidisease Care Management on the Mortality and Hospitalization of Seniors

OBJECTIVES: To explore changes in mortality and hospital usage for chronically ill seniors enrolled in a multidisease care management program, Care Management Plus (CMP).

Use of health-related, quality-of-life metrics to predict mortality and hospitalizations in community-dwelling seniors

OBJECTIVES: To investigate whether health‐related quality‐of‐life (HRQoL) scores in a primary care population can be used as a predictor of future hospital utilization and mortality.

Clinical questions raised by providers in the care of older adults: a prospective observational study

Objective To characterise clinical questions raised by providers in the care of complex older adults in order to guide the design of interventions that can help providers answer these questions. Materials and methods To elicit clinical questions, we observed and audio recorded outpatient visits at three healthcare organisations. At the end of each appointment, providers were asked to identify clinical questions raised in the visit. Providers rated their questions based on their urgency, importance to the patients care and difficulty in finding a useful answer to. Transcripts of the audio recordings were analysed to identify ageing-specific factors that may have contributed to the nature of the questions. Results We observed 36 patient visits with 10 providers at the three study sites. Providers raised 70 clinical questions (median of 2 clinical questions per patient seen; range 0–12), pursued 50 (71%) and successfully answered 34 (68%) of the questions they pursued. Overall, 36 (51%) of providers’ questions were not answered. Over one-third of the questions were about treatment alternatives and adverse effects. All but two clinical questions were motivated either directly or indirectly by issues related to ageing, such as the normal physiological changes of ageing and diseases with higher prevalence in the elderly. Conclusions The frequency of clinical questions was higher than in previous studies conducted in general primary care patient populations. Clinical questions were predominantly influenced by ageing-related issues. We propose a series of recommendations that may be used to guide the design of solutions to help providers answer their clinical questions in the care of older adults.

Implementation of Care Management: An Analysis of Recent AHRQ Research.

Care management (CM) is a promising team-based, patient-centered approach “designed to assist patients and their support systems in managing medical conditions more effectively.” As little is known about its implementation, this article describes CM implementation and associated lessons from 12 Agency for Healthcare Research and Quality–sponsored projects. Two rounds of data collection resulted in project-specific narratives that were analyzed using an iterative approach analogous to framework analysis. Informants also participated as coauthors. Variation emerged across practices and over time regarding CM services provided, personnel delivering these services, target populations, and setting(s). Successful implementation was characterized by resource availability (both monetary and nonmonetary), identifying as well as training employees with the right technical expertise and interpersonal skills, and embedding CM within practices. Our findings facilitate future context-specific implementation of CM within medical homes. They also inform the development of medical home recognition programs that anticipate and allow for contextual variation.

The role of information technology in translating educational interventions into practice: an analysis using the PRECEDE/PROCEED model

OBJECTIVE The evidence base for information technology (IT) has been criticized, especially with the current emphasis on translational science. The purpose of this paper is to present an analysis of the role of IT in the implementation of a geriatric education and quality improvement (QI) intervention. DESIGN A mixed-method three-group comparative design was used. The PRECEDE/PROCEED implementation model was used to qualitatively identify key factors in the implementation process. These results were further explored in a quantitative analysis. METHOD Thirty-three primary care clinics at three institutions (Intermountain Healthcare, VA Salt Lake City Health Care System, and University of Utah) participated. The program consisted of an onsite, didactic session, QI planning and 6 months of intense implementation support. RESULTS Completion rate was 82% with an average improvement rate of 21%. Important predisposing factors for success included an established electronic record and a culture of quality. The reinforcing and enabling factors included free continuing medical education credits, feedback, IT access, and flexible support. The relationship between IT and QI emerged as a central factor. Quantitative analysis found significant differences between institutions for pre-post changes even after the number and category of implementation strategies had been controlled for. CONCLUSIONS The analysis illustrates the complex dependence between IT interventions, institutional characteristics, and implementation practices. Access to IT tools and data by individual clinicians may be a key factor for the success of QI projects. Institutions vary widely in the degree of access to IT tools and support. This article suggests that more attention be paid to the QI and IT department relationship.

Individual versus interprofessional team performance in formulating care transition plans: A randomised study of trainees from five professional groups

ABSTRACT Health professions trainees’ performance in teams is rarely evaluated, but increasingly important as the healthcare delivery systems in which they will practice move towards team-based care. Effective management of care transitions is an important aspect of interprofessional teamwork. This mixed-methods study used a crossover design to randomise health professions trainees to work as individuals and as teams to formulate written care transition plans. Experienced external raters assessed the quality of the written care transition plans as well as both the quality of team process and overall team performance. Written care transition plan quality did not vary between individuals and teams (21.8 vs. 24.4, respectively, p = 0.42). The quality of team process did not correlate with the quality of the team-generated written care transition plans (r = −0.172, p = 0.659). However, there was a significant correlation between the quality of team process and overall team performance (r = 0.692, p = 0.039). Teams with highly engaged recorders, performing an internal team debrief, had higher-quality care transition plans. These results suggest that high-quality interprofessional care transition plans may require advance instruction as well as teamwork in finalising the plan.

Challenges of Noncancer Patients Transitioning to Hospice

The traditional model of hospice care based on the course of incurable cancer with rapid decline and death does not apply to chronic diseases. Cancer also may take a chronic course and no longer accounts for the majority of admissions to hospice. Hospice admissions now include a majority of noncancer diagnoses. The second challenge is the wide disparity between chronic disease courses. Case examples of people with different diagnoses demonstrate a variety of contrasting trajectories of illness. With ever-increasing advances in medical care, the indications for intensive treatments have never overlapped so much with the indications for hospice referral. This represents the third challenge. In addition, some treatments and medications that improve symptoms and quality of life may significantly prolong life, thus contradicting the traditional expectation of “foregoing life-sustaining treatment” in favor of enrolling in hospice. Finally, a description of various assessment tools helps in identifying the indications for hospice.